1174675292 NPI number — HEALTHY SMILES OF LAKEWAY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174675292 NPI number — HEALTHY SMILES OF LAKEWAY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHY SMILES OF LAKEWAY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174675292
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2422 RR 620 SOUTH
Provider Second Line Business Mailing Address:
#A 126
Provider Business Mailing Address City Name:
LAKEWAY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78734
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-263-8989
Provider Business Mailing Address Fax Number:
512-263-9095

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2422 RR 620 SOUTH
Provider Second Line Business Practice Location Address:
#A 126
Provider Business Practice Location Address City Name:
LAKEWAY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-263-8989
Provider Business Practice Location Address Fax Number:
512-263-9095
Provider Enumeration Date:
01/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOSNEY
Authorized Official First Name:
KIRSTEN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER DENTIST
Authorized Official Telephone Number:
512-263-8989

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  21080 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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